The motor and neurological consequences of stroke are a major health concern in the United States, affecting almost 800,000 people per year. The intricacy of neuromotor control required for hand function as well as the variation in recovery of manipulative abilities post-stroke, makes rehabilitation of the upper extremities, especially the hand, extremely challenging. The goal of this project is to expand and build on an ongoing multidisciplinary investigation of targeted therapeutic interventions that facilitate rehabilitation and motor recovery through plasticity- mediated therapies. It will augment several aspects of the therapeutic interventions that utilize virtual reality (VR) technology interfaced with arm/hand robotics to provide repetitive and intensive sensorimotor training needed to promote neuroplasticity and functional motor recovery after stroke. The major means of effecting this augmentation are 1) Expanding the existing VR games library to include games that require coordinated bilateral movement of the upper extremities, 2) optimizing the efficacy of these interventions via adaptive algorithms that manipulate task parameters or performance targets 3) The addition of kinetic measurements of standardized real-world object manipulation to examine the transfer of skills acquired in VR, 4) investigating whether the simultaneous excitation of motor cortical areas by Transcranial magnetic stimulation time-locked to the initiation of voluntary motor actions will strengthen long term potentiation and synaptic efficiency of the neural networks associated with upper extremity movements and 5) if this strengthening will further improve functional motor outcomes resulting from VR training. PUBLIC HEALTH RELEVANCE: My project aims to demonstrate the suitability of Virtual Reality training combined with transcranial magnetic stimulation as a system for remediation of upper extremity function in patients with hemiparesis. The findings of this project will advance our understanding of the neurophysiologic mechanisms underlying therapeutic interventions in the stroke population. Specifically, we will be able to evaluate the relative merits of the timing and complexity of the sensorimotor training as well as the effects of TMS as an assessment tool and training method.